Reverse Total
Shoulder
Arthroplasty
(Reverse TSA)
Heidi Church, SPTA
Fall Internship 2012
Salt Lake Orthopaedic Clinic
1160 East 3900 South, Suite 4050
Facts
•
Epidemiology - in United States there are ~53,000 total shoulder
arthroplasties per year compared to >900,000 total hip & total knee
arthroplasties per year (9)
•
Indications for a Reverse TSA - ~80% of patients needing a reverse
TSA have glenohumeral (GH) joint degradation and an inefficient rotator
cuff, while ~18% have a good GH joint, an irreparable rotator cuff injury,
and are >70 years of age. The remaining 2% have a failed TSA
•
90% to 95% of patients with osteoarthritis, requiring a TSA, have their
rotator cuff intact. That means 5%-10% have a deficient rotator cuff.
(10)
Shoulder Anatomy
Glenohumeral Joint
• Articular surface:
inclined 130˚-150˚to
the shaft of the
humerus, and
retroverted 20˚-30˚
(10)
Anatomy of shoulder after
Reverse TSA
• coracoid process of
scapula
• acromion
• humerus
• prosthetic ball
• prosthetic socket
• scapula
Biomechanics of Reverse
TSA
• glenoid center line “In a normal glenoid, the center line
represents a line perpendicular to the
articular surface of the glenoid and
directed, on average, approximately 10°
posterior (retroverted) to the plane of
the scapula (Fig. 5A–B). The center line
serves as the pillar under which the
humeral head rests; glenohumeral and
scapulothoracic motion are coupled to
maintain the center line beneath the
humeral head throughout the shoulder’s
ROM. (4) In cases of severe or
eccentric glenoid wear, a stable
baseplate fixation can only be achieved
by placing the component along the
alternate glenoid center line (Fig. 5C–
D). This alternate center line is defined
as a line aiming at the dense bone
where the scapular spine meets the
body of the scapula and is not
necessarily perpendicular to the
remaining glenoid face.”(4)
glenoid position of
prosthetic head
Forces on baseplate-bone
junction
Deltoid Muscle
= axis of rotation
When the axis of rotation is moved laterally,
the deltoid muscle’s movement becomes
one of rotation.
History of TSA/Reverse TSA (3)
•
1893 - first prosthetic shoulder arthroplasty - performed by French surgeon Jules Emile Péan
•
1955 - proximal humeral arthroplasty used to repair fractures - Neer
•
1970’s - surgeons face the challenge of developing a satisfactory prosthesis that balances
joint stability and ROM. Reversed normal anatomy designs for TSA
•
1972 - divergent threaded peg glenoid component - Leeds
•
1973 - Single central screw - Kessel. Hydroxyapatite coated large central screw (screw thread
diameter increased), center of rotation moved medially and distally - Bayley-Walker
•
1973-1981 - rotator cuff and constraint in total shoulder arthroplasty - Neer designs three
implants, Mark I, II, III
•
1975 - emphasis on enlarged ball-and-socket to increase glenohumeral motion and increase
deltoid lever arm - Fenlin
•
1978 - floating fulcrum, small glenosphere articulating with larger intermediate polyethylene
cup, to allow supraphysiologic motion. - Buechel
•
1985-1994 - Grammont’s system introduced, four key features: 1) prosthesis must be
inherently stable; 2) weightbearing part must be convex, and supported part must be concave;
3) center of sphere must be at or within glenoid neck; 4) center of rotation must be medialized
and distalized. 1991 - Grammont’s second generation design changed the glenosphere from
2/3 of a sphere to 1/2 a sphere, and the baseplate included a central press-fit peg and two
divergent 3.5-mm screws. 1994 - Grammont’s third variation changes directed toward the
humeral component.
Rehabilitation for the
Reverse TSA
(6)
•
Early Passive Motion (0-4 weeks) - wear sling to week 3, passive/selfpassive (pulley) ROM in forward flexion(FF) up to 90˚ and external
rotation(ER) up to 45˚
•
Active Assistive Motion (4-6 weeks) - self-passive (pulley) ROM in FF
up to 120˚, ER to 45˚
•
Active Motion (6-8 weeks) - active assistive ROM in FF up to 145˚ and
ER up to 45˚
•
Full Stretch (8-10 weeks) - full stretch in FF and ER, increase
isometric muscle contraction, and add small amounts of weight, as
tolerated
•
Strengthening (10-12 weeks) - increase weights and build deltoid
muscle strength
1}
2}
4}
3}
Early Passive Motion
(0-4 weeks)
1}Passive manual ROM forward flexion-90˚
2}Passive manual ROM external rotation to
45˚
3}Self-passive, with pulley, forward flexion
to 90˚
4}Self-passive, with pulley, external rotation
to 45˚
2}
1}
Active Assistive Motion
(4-6 weeks)
1} Active Assistive ROM, with pulley,
forward flexion to 120˚
2} Active Assistive ROM, with pulley,
external rotation to 45˚
3} Gripping exercises
1}
3}
2}
Active Motion
(6-8 weeks)
1}Pulley - forward flexion, external rotation
2}Ladder - forward flexion
3}Dowel supine - forward flexion
1}
2}
4}
3}
Full Stretch
(8-10 weeks)
1}Internal rotation stretch with belt,
horizontal/vertical
2}Supine horizontal adduction stretch
3}Ladder - forward flexion with isometric
hold off ladder
4}Dowel supine - forward flexion with
weight as tolerated
1}
2}
3}
Strengthening
(weeks 10-12)
1}Deltoid muscle strengthening - forward
flexion
2}Deltoid muscle strengthening - abduction
3}Internal rotation strengthening
Goals
• Decrease pain
• Improve range of motion
• Improve strength
• Improve functional ability
Complications
• Infection - any infection in the body can
spread to the prosthesis.
•
incision site
•
deep around prosthesis
•
minor - treated with antibiotics
•
major - may require surgery and removal of prosthesis
• Prosthesis problems
•
wear
•
components loosen
•
dislocation
• Nerve injury
Prognosis
• SLOC case study - pain < 1/10, SPADI
< 25%, percent of function 80%
• Revision rates of RTSA 4.2% - 13%
• Instability rate of 2.8%
• RTSA for cuff tear arthropathy “results in
major improvements” (7)
References
•
1) Acta Orthopaedica, Dec2010, Vol. 81 Issue 6, p719-726, 8p, 9 Diagrams, 1 Graph,
Diagram; found on p720
•
2) Nolan B, Ankerson E, Wiater J. Reverse Total Shoulder Arthroplasty Improves Function in
Cuff Tear Arthropathy. Clinical Orthopaedics & Related Research [serial online]. September
2011;469(9):2476-2482. Available from: Academic Search Premier, Ipswich, MA.
•
3) A History of Reverse Total Shoulder Arthroplasty, Evan L. Flatow, Alicia K. Harrison, Clin
Orthop Relat Res. 2011 September; 469(9): 2432–2439. Published online 2011 January 7.
doi: 10.1007/s11999-010-1733-6, PMCID: PMC3148354
•
4) How Reverse Shoulder Arthroplasty Works, Matthew Walker, Jordan Brooks, Matthew
Willis, Mark Frankle, Clin Orthop Relat Res. 2011 September; 469(9): 2440–2451. Published
online 2011 April 12. doi: 10.1007/s11999-011-1892-0, PMCID: PMC3148368
•
5) http://jimmysmithtraining.com/six-pack-diet/good-hurt-bad-hurt
•
6) Salt Lake Orthopaedic Clinic protocol for Reverse Total Shoulder Arthroplasty
•
7) Reverse Total Shoulder Arthroplasty Improves Function in Cuff Tear Arthropathy. Betsy M.
Nolan, Elizabeth Ankerson, J. Michael Wiater. Clin Orthop Relat Res. 2011 September;
469(9): 2476–2482. Published online 2010 November 30. doi: 10.1007/s11999-010-1683-z.
PMCID: PMC3148381
•
8) http://www.umm.edu/orthopaedic/rsr.htm
•
9) http://orthoinfo.aaos.org/topic.cfm?topic=A00094
•
10) Physical Therapy of the Shoulder, fourth edition, edited by Robert A. Donatelli
•
11)
http://my.clevelandclinic.org/services/shoulder_replacement/hic_total_shoulder_joint_replace
ment.aspx